Alzheimer's disease (AD) has become the model disease for the whole dementia syndrome with predominant memory deficits (World Health Organization, 1994). Other forms of neurodegenerative dementias – dementia with Lewy bodies (DLB) and frontotemporal degeneration (FTD) – are characterized by different patterns of neuropsychological performance and behavioral disturbances (Neary et al., 1998; McKeith et al., 2004). AD, DLB and FTD affect specific neuronal systems underlying different memory functions (Gabrieli et al., 1994; Moscovitch et al., 2005). Such differential effects on memory are associated with distinct effects on the perception of time. Concepts of time and their pathological change have not been considered as central issues in dementia research and care. This paper suggests that the altered perception of time in patients with different forms of dementia is largely neglected, and that clinical observations in dementia may improve our understanding of how the past, the present and the future are psychologically connected, a problem which philosophers have addressed repeatedly.

This synthetic review presents an approach to the use of biomarkers for the development of new treatments for Alzheimer's disease (AD). After reviewing the process of translation as applied to AD, the paper provides a general update on what is known about the biology of the disease, and highlights currently available treatments. This is followed by a discussion of future drug development for AD emphasizing the roles that biomarkers are likely to play in this process: (1) define patients who are going to progress rapidly for the purpose of trial enrichment; (2) differentiate disease and therapeutically relevant AD subtypes; (3) assess the potential activity of specific therapies in vivo or ex vivo; and (4) measure the underlying disease state, so as to (a) detect disease and assess drug response in asymptomatic patients, (b) serve as a secondary outcome measure in clinical trials of symptomatic patients, and (c) decide if further development of a treatment should be stopped if not likely to be effective. Several examples are used to illustrate each biomarker utility in the AD context.

Background: Falls are a major health problem among the elderly, particularly in nursing homes. Abnormalities of balance and gait, psychoactive drug use, and dementia have been shown to contribute to fall risk.

Methods: We conducted a systematic review of the literature to investigate which psychoactive drugs increase fall risk and what is known about the influence of these drugs on gait in nursing home residents with dementia. We included studies with a prospective cohort design on psychoactive drug use in nursing homes with dementia residents and with falls as an outcome measure.

Results: Seventeen studies were included in the review. Pooled risk estimates were not calculated because there was no homogeneity across studies. We assessed the strength of evidence for psychoactive drugs as a prognostic factor for falls by defining four levels of evidence: strong, moderate, limited or inconclusive. Strong evidence was defined as consistent findings (≥80%) in at least two high quality cohorts. We found strong evidence that the use of multiple drugs (3/3 cohorts, effect sizes 1.30–1xs0.30), antidepressants (10/12 cohorts, effect sizes 1.10–7.60), and anti-anxiety drugs (2/2 cohorts, effect sizes 1.22–1.32) is associated with increased fall risk. The evidence for the association of other psychoactive drug classes with fall risk was limited or inconclusive.

Conclusions: Research on the contribution of psychoactive drugs to fall risk in nursing home residents with dementia is limited. The scarce evidence shows, however, that multiple drugs, antidepressants and anti-anxiety drugs increase fall risk in nursing home populations with residents with dementia.

Background: Despite evidence that early identification of dementia is of growing policy and practice significance in the U.K., limited work has been done on evaluating screening measures for use in primary care. The aim of this paper is to offer a clinically informed synthesis of research and practice-based evidence on the utility, efficacy and quality of dementia screening measures.

Method: The study has three elements: a review of research literature, a small-scale survey of measures employed in three primary care trusts, and a systematic clinical evaluation of the most commonly used screening instruments. The study integrates data from research and clinical sources.

Results: The General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS), and the Mini-Cognitive Assessment Instrument (Mini-Cog) were found to be brief, easy to administer, clinically acceptable, effective, and minimally affected by education, gender, and ethnicity. All three have psychometric properties similar to the Mini-mental State Examination (MMSE).

Conclusions: Although the MMSE is widely used in the U.K., this project identifies the GPCOG, MIS and Mini-Cog as clinically and psychometrically robust and more appropriate for routine use in primary care. A coherent review of evidence coupled with an indepth evaluation of screening instruments has the potential to enhance ability and commitment to early intervention in primary care and, as part of a wider educational strategy, improve the quality and consistency of dementia screening.

Background: Group living homes are a fast-growing form of nursing home care for older people with dementia. This study seeks to determine the differences in job characteristics of nursing staff in group living homes and their influence on well-being.

Methods: We examined the Job Demand Control Support (JDCS) model in relation to 183 professional caregivers in group living homes and 197 professional caregivers in traditional nursing homes. Multilevel linear regression analysis was used to study the mediator effect of the three job characteristics of the JDCS-model (demands, control and social support) on job satisfaction and three components of burnout (emotional exhaustion, depersonalization and decreased personal accomplishment).

Results: Demands were lower in group living homes, while control and social support from co-workers were higher in this setting. Likewise, job satisfaction was higher and burnout was lower in group living homes. Analysis of the mediator effects showed that job satisfaction was fully mediated by all three psychosocial job characteristics, as was emotional exhaustion. Depersonalization was also fully mediated, but only by control and social support. Decreased personal accomplishment was partially mediated, again only by job characteristics, control and support.

Conclusion: This study indicates that working in a group living home instead of a traditional nursing home has a beneficial effect on the well-being of nursing staff, largely because of a positive difference in psychosocial job characteristics.

Background: People with dementia in care homes are at risk of having their views ignored and decisions are often made on their behalf by care home staff and family carers. The aim of this study was to compare the ratings of needs of older people with dementia living in care homes, as assessed by the older person themselves, a family caregiver, and the staff of the care home.

Method: The Camberwell Assessment of Need for the Elderly (CANE) was completed for 238 residents with dementia by care staff. In addition, 149 users and 81 family caregivers also completed the assessment of the person's met and unmet needs.

Results: Many users were able to report their met and unmet needs despite having moderately severe dementia. The views of the person with dementia were commonly in agreement with the staff and family carers' views. However, user and carer pairs had the lowest average percentage agreement of 63% compared to that of 77% between user and staff pairs. In particular, users reported relatively higher unmet needs for psychological distress, company and information, and high unmet needs for daytime activities and eyesight/hearing problems.

Conclusions: Users' views on their needs should be sought even when the person has dementia and lives in a care home. Reliance solely on assessment by staff or carers may lead to under recognition of unmet needs.

Background: Decreased initiation of activities is a common symptom in Alzheimer's disease (AD) and creates significant burden for carers, yet little is known about how patients, carers and treating physicians describe this problem.

Methods: This is a secondary, qualitative analysis of video-recorded, semi-structured and open-ended interviews with the 130 community-dwelling patients with mild-to-moderate AD from the Video-Imaging Synthesis of Treating Alzheimer's Disease (VISTA) study – a four-month, randomized, placebo-controlled trial of galantamine. Interviews were coded and organized using Atlas.ti. By applying a framework analysis approach, patient/carer descriptions of dementia-related decreased initiation of usual tasks and activities were categorized and summarized.

Results: Decreased initiation of instrumental activities of daily living (IADLs) and/or leisure and social activities was reported in 85/130 patients at baseline, 71 (84%) of whom specifically targeted increased initiation as a goal of treatment. The most common manifestations of decreased initiation were initiating only with prompting (55%), and no longer initiating but willing to engage in the activity (42%; note that these groups can overlap). Many patients were also described as having less interest (44%) or impaired performance (34%) in the activity in which decreased initiation was noted. Coping strategies were employed by 69/85 carers, most commonly verbal prompts to begin an activity.

Conclusion: Decreased initiation is a common and problematic symptom in people with mild-to-moderate Alzheimer's disease who seek treatment for dementia. Information offered voluntarily about interest in or ability to perform activities which are initiated less often gives additional data compared with routine questioning about initiation of function. This is a potentially rich area for the elucidation of disease and treatment effects.

Background: Apathy and depression may be strongly associated with executive dysfunction in Alzheimer's disease (AD). The Frontal Assessment Battery (FAB) is an instrument for assessing executive function. The dual task paradigm is also useful for assessing divided attention. However, the association between apathy/depression and these tasks is unclear.

Methods: Both the FAB and the dual task were used to evaluate AD patients. A two-way analysis of variance was then conducted between the FAB and dual task results and the absence versus the presence of depression or the absence versus the presence of apathy.

Results: Of 88 patients with AD, 26 had both apathy and depression, 26 had depression only, 18 had apathy only, and 18 had neither. Total FAB scores and dual task scores differed significantly between the AD patients with depression and those without depression; the scores were also different between those with apathy and those without apathy. Also, a significant interaction between depression and apathy was noted for the total FAB and dual task scores.

Conclusions: The deficits in the total FAB and dual task scores were larger in AD patients with both apathy and depression compared with patients with either apathy or depression alone. AD patients with both symptoms may have greater deficits in frontal lobe function relative to AD patients with either apathy or depression alone.

Background: This study aims to establish the incidence rates of Alzheimer's disease (AD) and to understand the relations between illiteracy and AD in the Korean Yonchon survey cohort.

Methods: A community-based, dementia-free cohort of 966 people aged 65 years and older was followed up for an average of 5.4 ± 1.60 years to detect incident AD cases using a two-phase procedure. Age-specific incidence rates were calculated using a person-years approach with Poisson distribution confidence intervals. Data were analyzed using the Cox proportional hazards model to find the hazard ratio of illiteracy.

Results: The participating percentage of the survivors was 86.4% and 74 subjects were diagnosed with AD. Incidence rates per 1000 person-years were 20.99 (95% CI 16.48 to 26.35) for AD. The hazard ratio of illiteracy was 1.78 (95% CI 1.08 to 2.93) adjusted for age, sex, educational level. AD developed more rapidly with aging in the illiterate group than in the literate group.

Conclusions: Illiteracy is associated with a higher risk of AD and the risk increases with age.

Background: Practice effects have been widely reported in healthy older adults, but these improvements due to repeat exposure to test materials have been more equivocal in individuals with mild cognitive impairment (MCI).

Methods: The current study examined short-term practice effects in MCI by repeating a brief battery of cognitive tests across one week in 59 older adults with amnestic MCI and 62 intact older adults.

Results: Participants with amnestic MCI showed significantly greater improvements on two delayed recall measures (p < 0.01) compared to intact peers. All other practice effects were comparable between these two groups. Practice effects significantly improved scores in the MCI group so that 49% of them were reclassified as “intact” after one week, whereas the other 51% remained “stable” as MCI. Secondary analyses indicated the MCI-Intact group demonstrated larger practice effects on two memory measures than their peers (p < 0.01).

Conclusions: These results continue to inform us about the nature of memory deficits in MCI, and could have implications for the diagnosis and possible treatment of this amnestic condition.

Background: This study evaluates the predictive effects of different aspects of volunteering (e.g. volunteering status, number of hours, number of years, and type of volunteering activity) on all-cause mortality.

Methods: A seven-year follow-up dataset of a nationally representative sample of Israelis, 60 years and older was used.

Results: As expected, volunteering was associated with a reduced mortality risk even after adjusting for age, gender, education, baseline mental health and physical health, activity level, and social engagement. Those who volunteered for 10 to 14 years had a reduced mortality risk relative to non-volunteers. In addition, those who volunteered privately, not as part of an official organization, also had a reduced mortality risk compared to non-volunteers. The number of hours of volunteering was not a significant predictor of all-cause mortality in the fully adjusted model. In additional sensitivity analyses limited to those who volunteered, none of the various aspects of volunteering was associated with a reduced mortality risk.

Conclusions: Results suggest that not all aspects of volunteering have the same predictive value and that the protective effects of length of volunteering time and type of volunteering are particularly important. However, whether or not volunteering is the most consistent predictor of mortality and whether once a person volunteers the various aspects of volunteering are no longer associated with mortality risk.

Background: The aim of the study was to determine the amount of trauma impact and significant post-traumatic stress symptoms, which can indicate a possible post-traumatic stress disorder (PTSD), in a sample of former German child soldiers of World War II.

Methods: 103 participants were recruited through the press, then administered a modified Post-traumatic Diagnostic Scale (PDS).

Results: Subjects reported a high degree of trauma exposure, with 4.9% reporting significant post-traumatic stress symptoms after WW II, and 1.9% reporting that these symptoms persist to the present.

Conclusion: In line with other studies on child soldiers in actual conflict settings, our data document a high degree of trauma exposure during war. Surprisingly, the prevalence of significant post-traumatic stress symptoms indicating a possible PTSD was low compared to other groups of aging, long-term survivors of war trauma. Despite some limitations our data highlight the need for further studies to identify resilience and coping factors in traumatized child soldiers.

Background: Few studies have looked at healthcare professionals' knowledge of and attitudes to later life sexuality in both Western and Eastern cultures. Here we examine the attitudes and knowledge of Turkish medical doctors toward sexuality in older people.

Method: Eighty-seven doctors, from various specialties, who were directly involved in the care of older people, were contacted by post and asked to complete the Turkish version of the Aging Sexual Knowledge and Attitudes Scale (ASKAS).

Results: A majority of physicians indicated that they had limited information and knowledge regarding sexual health issues in older people (69%). Although a small percentage (14.5%) reported that they “always” discuss sexuality and sexual problems with older patients, the majority (69%) indicated that they “sometimes” raise questions about sexuality with these patients. A high percentage (81%) stated that they would be helpful and receptive should an elderly patient initiate a discussion about sexual issues. Most participants (77%) thought that the patient's gender was of no importance when taking a sexual history. Overall, the responses to ASKAS showed that physicians had limited knowledge but their attitude was positive toward sexuality in the elderly. Female physicians had less knowledge than males and had more negative attitudes toward sexuality in this age group. Total and knowledge subscale scores of ASKAS showed that older physicians had more knowledge than younger physicians but similar attitudes. A comparison of the knowledge and attitude scores of psychiatrists, surgeons and non-surgeons showed no significant difference among the three groups.

Conclusion: This study identified a low level of awareness of later life sexuality among Turkish medical doctors. These findings identify a need to improve the education and training of doctors at both undergraduate and postgraduate levels to enable them to provide better sexual health care to older people.

Background: This study aims to evaluate the prevalence of depressive symptoms and associated factors among elderly hospital inpatients.

Methods: A cross-sectional study evaluated 189 participants using the Geriatric Depression Scale, the Mini-mental State Examination and the Katz and Lawton Index, to assess dependence regarding activities of daily living (ADL).

Results: Most of the participants were women, aged between 60 and 92 years, with low levels of educational attainment and personal income, and non-qualified occupations. The prevalence of depressive symptoms was 56%, but only 3% had a psychiatric diagnosis registered in their medical records. Univariate analysis showed significant associations between depressive symptoms and low educational level and income, marital status, number of hospitalizations in the previous year, cognitive decline, dependence regarding basic and instrumental ADL, and death. After logistic regression, the only variables that remained significantly associated with depression were low educational level, dependence regarding basic ADL, and death.

Conclusions: Depressive symptoms were independently associated with low educational level and dependence regarding basic ADL. Hospitalized elderly people with depressive symptoms were more likely to die. It is essential to diagnose and treat depression properly in this population to minimize its negative impacts.

Background: The population size of the elderly from ethnic minority groups in many developing countries is rapidly increasing. The authors perceived a paucity of publications in the geriatric psychiatry literature pertaining to ethnic minority elders.

Methods: A study examining the proportion of research publications pertaining to ethnic minority elders in two leading geriatric psychiatry journals, International Psychogeriatrics and International Journal of Geriatric Psychiatry, was undertaken.

Results: The main findings were: (1) overall only 7.6% of the publications examined ethnic minority elders; (2) only 5.1% of publications were exclusively of ethnic minority elderly groups; and, (3) only 2.5% of publications included ethnic minority elderly groups in their overall sample.

Conclusions: Findings from studies, such as epidemiological studies of risk factors for mental disorders in old age and randomized controlled studies of treatment interventions, which exclude ethnic minority elders, cannot be assumed to apply to these groups. Researchers, research institutions, funding organizations and policy-makers should acknowledge the rising numbers of ethnic minority elders and recognize the importance of using ethnic minority-specific research data in the planning of culturally sensitive services and mental health promotion programs.

Background: Research concerning negative attitudes toward the elderly among samples of North American respondents has uncovered two distinct yet comparable three-factor structures: (1) avoidance, antilocution and separation; and (2) discrimination, stereotypes and affective attitudes. In addition, previous research has demonstrated that men and younger people have more negative attitudes toward the elderly than do women and older people. The aim of this study is to examine the extent to which these findings can be generalized to individuals from a different culture.

Method: The Fraboni Scale of Ageism (FSA) was administered to 491 Israeli participants aged 20–50 years.

Results: Exploratory factor analysis with varimax rotation uncovered a three-factor structure, similar to previous investigations. In contrast to the literature, however, no simple group (gender, age) differences were found for ageism. However, discriminant function analysis revealed a more complex relationship between age, gender and ageism. Older males, in contrast to older females, demonstrated a tendency to perceptions of the elderly that associated avoidance of the elderly with negative stereotypes whereas older females, in contrast to younger females, held perceptions that associated avoidance of the elderly with a negative perception of the elderly person's contribution to society.

Conclusions: Despite cultural differences between Israel and North America, the similarity of findings provides support for the generalizabilty of the structure of attitudes toward the elderly as measured by the FSA to various cultures. In addition, the combined effect of age and gender on differential forms of ageism is complex and should be examined in future research.

Background: Increasing evidence suggests that functional impairment can be detected in older persons with mild cognitive impairment (MCI). This study explores the functional profiles and the clinical correlates of a population-based sample of Chinese older persons with MCI in Hong Kong.

Methods: A random sample of 765 Chinese elderly subjects without dementia was recruited, of which 389 were elderly normal controls (Clinical Dementia Rating = 0), and 376 had questionable dementia (CDR = 0.5). The latter were categorized into an MCI group (n = 291) and a very mild dementia (VMD) group (n = 85). Their functional performances were measured and compared with the normal controls (NC). Multiple regression analyses investigated the associations between functional scores (Disability Assessment in Dementia) and clinical correlates (cognitive test scores, neuropsychiatric symptoms and motor signs) in the NC subjects and cognitively impaired subjects.

Results: Subjects with MCI had intermediate functional performance between the NC and those with VMD. Regression analyses revealed that lower scores of cognitive tests (delayed recall and categorical verbal fluency tests), apathy, aberrant motor symptoms and parkinsonism features were associated with lower functional scores in clinically non-demented subjects. Functional scores had no correlation with age, education and medical illness burden.

Conclusion: Neuropsychiatric symptoms and parkinsonism features were associated with functional impairment in the clinically non-demented elderly in the community. Assessment of these should be incorporated in the evaluation of older persons for early cognitive impairment.

Suicide rates have traditionally been thought to increase with age (Shah and De, 1998). A recent cross-national study of 62 developing and developed countries has reported an increase in suicide rates with aging in males and females in only 25 and 27 countries respectively (Shah, 2007a). Public health initiatives are being developed in many countries to facilitate reduction in suicide rates including those in the elderly (e.g. Chiu et al., 2003; Shah, 2007b). Such initiatives in the U.K. included legislation requiring general practitioners to offer annual physical and mental examinations to those over the age of 75 years, the Defeat Depression Campaign organized by the Royal College of Psychiatrists and the Royal College of General Practitioners, the governmental “Our Healthier Nation” suicide reduction targets, the National Confidential Enquiry into Suicides and Homicides, the National Service Frameworks for Mental Health and for Older People, and the National Suicide Prevention Strategy (Shah, 2007b).